Clinical characteristics & outcome of SARS-CoV-2 infected neonates presenting to paediatric emergency

Background & objectives: Data on neonatal COVID-19 are limited to the immediate postnatal period, with a primary focus on vertical transmission in inborn infants. This study was aimed to assess the characteristics and outcome of COVID-19 in outborn neonates. Methods: All neonates admitted to the paediatric emergency from August 1 to December 31, 2020, were included in the study. SARS-CoV-2 reverse transcription- (RT)-PCR test was done on oro/nasopharyngeal specimens obtained at admission. The clinical characteristics and outcomes of SARS-CoV-2 positive and negative neonates were compared and the diagnostic accuracy of a selective testing policy was assessed. Results: A total of 1225 neonates were admitted during the study period, of whom SARS-CoV-2 RT-PCR was performed in 969. The RT-PCR test was positive in 17 (1.8%). Mean (standard deviation) gestation and birth weight of SARS-CoV-2-infected neonates were 35.5 (3.2) wk and 2274 (695) g, respectively. Most neonates (11/17) with confirmed COVID-19 reported in the first two weeks of life. Respiratory distress (14/17) was the predominant manifestation. Five (5/17, 29.4%) SARS-CoV-2 infected neonates died. Neonates with COVID-19 were at a higher risk for all-cause mortality [odds ratio (OR): 3.1; 95% confidence interval (CI): 1.1-8.9, P=0.03]; however, mortality did not differ after adjusting for lethal malformation (OR: 2.4; 95% CI: 0.7-8.7). Sensitivity, specificity, accuracy, positive and negative likelihood ratios (95% CI) of selective testing policy for SARS-CoV-2 infection at admission was 52.9 (28.5-76.1), 83.3 (80.7-85.6), 82.8 (80.3-85.1), 3.17 (1.98-5.07), and 0.56 (0.34-0.93) per cent, respectively. Interpretation & conclusions: SARS-CoV-2 positivity rate among the outborn neonates reporting to the paediatric emergency and tested for COVID-19 was observed to be low. The selective testing policy had poor diagnostic accuracy in distinguishing COVID-19 from non-COVID illness.

Profile of Back-Referrals to Special Newborn Care Units

Objective: To study the outcomes of neonates back-referred from a tertiary care centre to special newborn care units (SNCUs) for step-down care. Methods: This prospective cohort study was conducted at a tertiary care neonatal unit and SNCUs in neighbouring states. We studied preterm and term neonates back-referred to district SNCUs from September, 2018 to April, 2019. The infants were followed up till 3 months corrected age, for mortality, re-hospitalization, emergency visits and unscheduled outpatient visits. Preterm inborn neonates <32 weeks gestation discharged directly to home formed the controls. Results: 201 back-referred neonates (study cohort) and 55 preterm neonates discharged to home (controls) were followed up till 3 months corrected age. Amongst the back-referred neonates, 5% died, 7% required re-hospitalization, 11% made emergency visits, and 24% made unscheduled outpatient visits. These outcomes were similar to the controls. Conclusion: Back-referral of convalescing neonates is a safe method of utilizing the limited healthcare resources in tertiary care centers in developing country settings.

Multicystic encephalomalacia: An autopsy report of 4 cases

Multicystic encephalomalacia is varying sized cystic lesions in the brain encountered in developing fetuses or infants. These cysts start at the periventricular area and may extend onto the cortex. The cause of the formation of these cystic lesions is secondary to an ischemic or hypoxic insult, which leads to liquefactive necrosis and subsequent formation of gliotic cyst walls having an admixture of microglia. We discuss four autopsy cases that had multicystic encephalomalacia to highlight the scenarios in which these lesions are encountered.

Severe Pulmonary Arteriopathy in a Neonate with Congenital Rubella Syndrome and Patent Ductus Arteriosus

Neonates with congenital rubella syndrome (CRS) are known to have associated congenital cardiac malformations. Patent ductusarteriosus (PDA) is one the most common cardiac anomalies associated with CRS. PDA refractory to medical management andassociated with ventilatory dependence is considered for surgical ligation. However, the management of PDA can be challenging in thepresence of underlying lung disease or pulmonary vascular disease. Outcomes after closure in neonates are dependent upon age,weight, nutritional status, pre-operative pulmonary arterial hypertension and presence of chronic lung disease. We present a neonatewith CRS who required surgical PDA closure. The neonate developed severe pulmonary arterial hypertension which led to fatal outcome.The clinical course is corroborated with histo-pathological changes observed on the autopsy of this neonate.

Optimizing Utilization of Laboratory Investigations in Neonatal Intensive Care Unit

Objective: To optimize utilization of laboratory tests by measuringbaseline rates and appropriateness of investigations, assessingthe barriers to rational use, and developing and implementing aneducational package for resident doctors.Design: Quality improvement study.Setting: Neonatal intensive care unit (NICU) from August, 2015 toDecember, 2016.Participants: All neonates admitted in NICU and resident doctorsworking in NICU.Intervention: Addressing barriers, educational package, postersand group discussions.Main outcome measures: Laboratory test rates for hematology,biochemistry and blood gas. Proportion of tests judged to beinappropriate.Results: At the baseline, median (IQR) laboratory test ratepatient/day was 0.6 (0.2-1.5) and one-fifth of tests were classifiedas inappropriate. Mechanical ventilation and sepsis wereindependent predictors of laboratory test rates but could explainonly 35% of the disparities, indicating variations in clinicalpractice. Following a short period of intervention, hematologyinvestigations showed a trend towards reduction, though overalltest rates did not change significantly.Conclusions: Addressing barriers, creating awareness andeducational interventions were able to bring down hematologylaboratory test rates in a short period. A longer period of sustainedintervention is required to demonstrate significant effects on testordering behavior

Reducing Healthcare-associated Infections in Neonates by Standardizing and Improving Compliance to Aseptic Non-touch Techniques: A Quality Improvement Approach

Objective: To standardize and improve compliance to Asepticnon-touch techniques (ANTT) for commonly performedprocedures in Neonatal intensive care unit (NICU) throughapplication of Model for improvement, and study its impact onHealthcare-associated infection (HCAI) rates.Design: Quality improvement project utilizing multiple Plan-Do-Study-Act (PDSA) cycles.Setting: Tertiary-care neonatal unit.Participants: All resident doctors and nurses working in neonatalunit were subjects for assessment of compliance to ANTT. Alladmitted neonates staying in hospital for more than 48 hours weresubjects for HCAI data collection.Procedure: Most frequently performed procedures in NICU wereidentified and pictorial Standard Operating Procedures (SOP)were developed. Implementation and uptake was reinforced bymeans of PDSA cycles. Compliance to ANTT was assessed asproportion of components to which adherence was documented.Trend of HCAI rates in unit were analyzed using process controlcharts.Main outcome measure: Change in compliance to ANTT formost frequently performed procedures.Results: Significant improvement in compliance to ANTTpractices was observed, specifically in use of procedure tray/trolley (16% to 49%, P=0.001), iv hub scrubbing (0% to 60%,P=0.001), local skin cleaning (33% to 67%, P=0.004), personalprotective equipment use (55% to 80%, P=0.02) and disposal(27% to 51%, P=0.03), use of non-touch technique (50% to 70%,P=0.001) and reduction in key part contamination (45% to 31%,P=0.03). A modest decrease in HCAI rates was seen in the shortperiod of observation after implementation.Conclusions: Substantial improvements in compliance toaseptic non-touch techniques can be ensured by adopting acombination of initial intensive teaching and sustaining throughmultiple PDSA cycles, targeting specific areas revealed by audits.

Comparison of Three Nursing Positions for Reducing Gastric Residuals in Preterm Neonates: A Randomized Crossover Trial

Objective: To compare left lateral, right lateral, and pronenursing positions of neonate for reducing pre-feed gastricresiduals among ?34 weeks neonates.Design: Randomized crossover trial.Setting:Level-III NICU.Participants: Neonates ?34 weeks, receiving 50-150 mL/kg/day feeds through oro-gastric route.Intervention: Neonates were randomized to left lateral, rightlateral and prone positions. Intervention position was given foreight hours (4 feeds, 9AM to 5PM) followed by a wash-off period of16 hours. After 24 hours, each neonate crossed over to nextposition as per randomization card to complete three positions inthree consecutive days. Gastric residuals were collected justbefore next feed.Main outcome:Pre-feed gastric residuals.Results:Sixty three neonates were randomized. Fewer neonatesin right lateral position had gastric residuals compared to leftlateral position [OR 0.09 (95% CI 0.04, 0.21), P<0.001]. Neonatesin right lateral and prone positions had comparable gastricresiduals [OR 0.90 (95% CI 0.36, 2.22), P=0.82]. Gastricresiduals, as a proportion of last feed, were highest in left lateral[6% (2, 10), maximum 28%] position. Significantly higherproportion of neonates in right lateral position had episodes ofregurgitation compared to other positions. Oxygen saturation,heart rate, time to full feeds and duration of hospital stay werecomparable in the three groups.Conclusions: Left lateral position was associated with higher butclinically non-significant pre-feed gastric residuals as comparedto right lateral position. Right lateral position was associated withsignificantly increased regurgitation episodes

Continuous Positive Airway Pressure in Preterm Neonates: An Update of Current Evidence and Implications for Developing Countries.

Context: Continuous Positive Airway Pressure (CPAP) is a cost-effective and minimal invasive respiratory support for the newborn. Objective: To review the evidence related to various aspects of CPAP usage and its applicability for developing countries. Evidence Acquisition: We conducted a literature search on PubMed, CENTRAL, and Cochrane Database of Systematic Reviews using the terms ‘CPAP’ OR ‘continuous positive airway pressure’ OR, non-invasive ventilation’ AND ‘newborn’ OR ‘neonate’ OR ‘infant’. We also searched the reference lists from the above articles and of review articles. Extracted manuscripts and reviews were analyzed and results related to various aspects of CPAP usage were summarized in narrative form. Results: Early use of CPAP with early rescue surfactant (InSurE) is the ideal approach for management of respiratory distress syndrome in preterm and extremely preterm infants. Delivery room CPAP is feasible and reduces the need for surfactant and mechanical ventilation by nearly 50%. Prophylactic surfactant for extreme preterms should be discouraged. Heated humidified high flow nasal cannula is best utilized for post-extubation respiratory support. The search for ideal interface still continues and binasal prongs or nasal masks are the good contenders. Evidence on the ideal CPAP delivery is still inconclusive. Conclusions: CPAP, if used early and judiciously, is an effective intervention and need immediate scaling-up in resource-limited settings. Future research should focus on the ideal interface and the CPAP delivery methods.

Off-label Use of Drugs in Neonatal Intensive Care Units.

Objective: To estimate proportion of off-label medication use in neonates and to evaluate evidence of efficacy and safety of these medications. Methods: Chart audit in neonatal intensive care units of two institutions in Chandigarh, India. Results: Among 568 prescriptions in 156 neonates, 286 (50%) were off-label. Of these, 56% drugs were not approved for use in neonatal age group and 26% prescriptions were off-label for frequency, dose, indication, route or rate. Most common off-label drugs were anti-infective and antiepileptic. Despite lack of regulatory approval, one-third off-label drugs had level I-II evidence of safety and efficacy for use in neonates. Conclusion: Use of off-label drugs is common in sick neonates.

Short Course Versus 7-Day Course of Intravenous Antibiotics for Probable Neonatal Septicemia: A Pilot, Open-label, Randomized Controlled Trial.

Objective: To compare a short course of antibiotics (48 to 96 hours) and a standard course of antibiotics (7 days) for probable neonatal sepsis. Design: Randomized, controlled, open-labeled trial with blocking and stratification according to birth weight. Setting: Tertiary care, referral, teaching hospital in Northern India. Participants: Neonates >30 wks gestation and >1000 g at birth, with probable sepsis (clinical signs of sepsis, raised C-reactive protein) were enrolled. Babies with major malformations, severe birth asphyxia, meningitis, bone or joint or deep-seated infection, those who were already on antibiotics, and those undergoing surgery were excluded. Neonates, who had clinically remitted on antibiotic therapy – by the time a sterile blood culture report was received – were randomized. Intervention: In the intervention arm, antibiotics were stopped after the 48-hour culture was reported sterile. In the control arm, antibiotics were continued to a total of 7 days. Main outcome measure: “Treatment failure” defined as reappearance of signs suggestive of sepsis within 15 days of stopping antibiotics, supported by laboratory evidence and adjudicated by a blinded expert committee. Results: 52 neonates were randomized to receive a short course or 7-day course (n=26 each). Baseline variables were balanced in the 2 groups. There was no significant difference in the treatment failures between the 2 groups (3 babies in the 7-day group vs none in short course group, P=0.23). Conclusion: No difference in the treatment failure rates could be identified between short course and 7-day groups among neonates >30 weeks and >1000 grams with probable sepsis.

Neonatal adrenal hemorrhage with intraperitoneal spill managed conservatively.

A neonate presented with anemia, hyperbilirubinemia and bilateral flank fullness at 23 days of age. Ultrasound abdomen showed bilateral adrenal hemorrhage with intraperitoneal extension on the left side. This was managed nonoperatively and the hematoma resolved completely. Literature regarding this rare entity is described.